Nokea
A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure?
- A. Lying in bed on the affected side
- B. Lying in bed on the unaffected side
- C. Sims position with the head of the bed flat
- D. Prone with the head turned to the side and supported by a pillow
Correct Answer: B
Rationale: The client should be assisted to lie in bed on the unaffected side for a thoracentesis procedure. This position allows for better access to the pleural space for the insertion of a needle to aspirate the fluid or air. Gravity helps to separate the fluid or air, making it closer to the chest wall for easier removal. Additionally, this position reduces the risk of injury to the lung or other structures, as the needle is directed away from these vital structures. Lying on the unaffected side also helps in preventing potential complications and ensures the safety and effectiveness of the procedure.
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The labor progress and the physician performed amniotomy. Nurse Hope should FIRST assess tor _______.
- A. bladder distention
- B. maternal blood pressure
- C. cervical dilatation
- D. fetal heart rate (FHR) pattern
Correct Answer: D
Rationale: Following an amniotomy procedure during labor, Nurse Hope's priority should be to assess the fetal heart rate (FHR) pattern. This assessment is crucial to ensure the well-being and safety of the fetus. Changes in the FHR can provide valuable information about fetal distress or complications, allowing for timely interventions if needed. Monitoring the FHR pattern is a standard practice during labor and delivery to track the fetus's response to the changes in uterine activity. Therefore, assessing the FHR pattern should be the first priority after a labor progress and amniotomy.
Nurse Jen, distributed the patient satisfaction form to the admitted patients in the hospital, this tool is in compliance to the quality standards.
- A. human resource
- B. patient care
- C. organizational structure
- D. legal -ethical
Correct Answer: B
Rationale: The distribution of patient satisfaction forms by Nurse Jen directly relates to patient care. By collecting feedback from admitted patients, the hospital can assess the quality of care being provided and identify areas for improvement. This initiative falls under patient care as it focuses on enhancing the overall experience and well-being of the patients, aligning with quality standards that prioritize patient satisfaction and outcomes.
A nurse is resistant to the change and is not taking an active part in facilitating the process of change. Which is the BEST approach in dealing with the nurse?
- A. Exert coercion on the nurse
- B. Provide a positive reward system for the nurse
- C. Talk and encourage verbalizing feelings of the change
- D. Ignore the resistance of the nurse.
Correct Answer: C
Rationale: The best approach in dealing with a nurse who is resistant to change and not actively participating is to communicate and encourage verbalizing feelings about the change. By talking with the nurse and allowing them to express their concerns and feelings, you can address any underlying issues that may be causing the resistance. This approach can help build trust, improve communication, and ultimately increase the nurse's engagement in the change process. Coercion (Choice A) can create negative feelings and resistance, while ignoring the nurse's resistance (Choice D) will not resolve the issue. Providing positive rewards (Choice B) may be helpful but may not address the underlying reasons for resistance. Communication is key in addressing resistance to change and fostering a positive, open environment for all involved.
After several days in the hospital, the physician ordered the patient to be discharged. Which of the following is a PRIORITY restriction that you should emphasize when he goes home?
- A. Stool softener to induce bowel elimination.
- B. Driving if not using narcotic drug.
- C. Take shower even if ´still with surgical drain.
- D. Lifting of objects not more than 10 lbs.
Correct Answer: D
Rationale: The priority restriction that should be emphasized when the patient is discharged from the hospital is the lifting of objects not more than 10 lbs. This is important to prevent any strain on the body, especially if the patient is still recovering or weak from their hospitalization. Lifting heavy objects can lead to complications, injuries, or setbacks in the recovery process. It is essential for the patient to follow this restriction to promote healing and avoid any further health issues.
Which of the following definition MOST accurately describes meningomyelocele? It is _______.
- A. Spinal cord tumor containing nerve roots.
- B. Complete exposure of the spinal cord and meninges.
- C. Herniation of spinal cord, cerebro-spinal fluid and meninges into a sac.
- D. Sac formation containing meninges and spinal fluid.
Correct Answer: C
Rationale: Meningomyelocele is a type of neural tube defect where there is a protrusion of the spinal cord, cerebrospinal fluid, and meninges through a defect in the vertebrae, forming a sac on the surface of the back. This condition occurs during fetal development when the neural tube fails to close completely, leading to the exposure of the spinal cord and its coverings. This herniation can result in a range of neurological deficits and complications, requiring surgical repair shortly after birth to prevent further damage and infections.